Category Archives: The Other Skills

There are parts of the resuscitation with no algorithm. No protocol. How do we improve that part? What are the social resuscitation skills we need to work on? We’re very pleased to have Dr Ruth Parsell chip in with some thoughts. Ruth is a current ACEM Registrar working on the CareFlight Rapid Response Helicopter in Sydney. She joined the NSW Ambulance Service in 1998 and has worked in prehospital and hospital settings in varying roles since that time.

The “social” resuscitation is a term I’ve been using for quite some time now. I apply it in dire situations. In both adults and children. But this is about the paediatric resuscitation and, specifically, cases where the prognosis is highly likely to be tragic. It is in these cases that I utilize this term because we are clearly treating more than just the patient when we resuscitate. I use the term because when I treat the child I am treating their family and all of the social connections that are linked to such a brief, precious life.

Experience We Don’t Always Want to Gain

The sad reality is that every paediatric resuscitation we do offers an opportunity to improve more than just our clinical skills. We all wish we didn’t see these cases but if they continue to occur then we will continue to do our best to serve the needs of both the patients and their families. What if we were able to improve the way we serve them? Which part of the resuscitation we call “futile” is the opposite of futile?

The best way to do both would be to have the “miracle” recovery. The “against all odds”, the “everything was against them”… the full recovery of a child who has had a terrible insult. The drowning, the fall, the pedestrian, the horse riding accident… all the terrible insults we see and all those mechanisms of injury that can potentially cause an early cardiac arrest or a moribund child.

Instantly we think of our algorithms, our protocols, our list of reversible causes and the sequence of steps we might take when we arrive at the scene. We hear the age, we think about weights, sizes, drug calculations. None of this should ever change and I’m not suggesting it should.

But what about when we hit that turning point?

It may have been an inkling early on. The thought that the mechanism is just too great, the injury just too severe, a poor response to even the most efficiently and expertly performed algorithm. It’s a moment where, sometimes even without verbalizing, the whole team is aware of the magnitude of the odds against this little one.

The Pause

What if in these cases we took a moment? Just a brief moment. When it comes to adult resuscitations I find we seem to automatically provide explanations to the family even while we are working. To explain that his heart is not beating and that we are working very hard to restart it; with a breathing tube, trying to stop the bleeding and with powerful medicines.

Perhaps it feels automatic because we just see more of those cases. We get to drill those algorithms more so there is a window that gives us space to look around.

So how do we provide this window in those paediatric prehospital jobs?

What if it was just a kiss before the transport? What if the family could have a little more from us? What if we suggested getting their daughter’s favourite teddy or blanket from the house? Just to fill their arms for the trip to hospital, to stop Mum’s hands from relentlessly wringing or something to give her tears a soft landing when they fall.

What do the books say?

The evidence for family presence during resuscitation has evolved over many years. Factors examined include the resuscitation team performance, stress levels amongst staff, clinical outcomes and psychological outcomes for family members. The evidence in paediatrics, including in some randomized control trials, demonstrates that there are improved measures of coping and positive emotional outcomes among families (1). These outcomes are achieved without impeding team performance.

There are many barriers to family presence in the pre-hospital arena. These scenes can be highly distressing, emotions are raw and the procedures required are time critical. Transport logistics can be a huge barrier too. It is rarely practical for a family member to travel with a child to hospital when they are critically unwell or in cardiac arrest. The confined environment of the back of an ambulance is usually congested and the potential unpredictability of a relative may compromise staff safety. The evidence regarding family presence is also more difficult to obtain.

I use this term in cases where I feel the resuscitation efforts are more a resuscitation for a family than the patient. I use it in the context of transporting to an appropriate place, where I feel that the optimal ongoing social supports for family members can be best met. Somewhere where others can assist with tissues, quiet rooms and hushed explanations. Somewhere where others can understand the welled up look that we give them when we enter the bay.

Now I think that the social resuscitation needs to start earlier. A more conscious and deliberate effort. Maybe not every time. Not when you can feel yourself buckling under the cognitive load. Not when your emotions are so close to the surface you can’t get the words out. Not when the scene is like a powder keg and you might just be putting people at risk.

But in those paediatrics cases we need to make a conscious effort to find a window, even where the algorithm is crowding us a little more. That might be the part of the resuscitation that isn’t futile for those left behind.

Try the explanation. Try the kiss. Wait for that teddy. Just try it and let’s see if it improves our social resuscitations. It might even just improve things for all of us.

We welcome to the blog a new contributor. Greg Brown has a background in nursing and is one of the people who makes education at CareFlight happen, and with courses happening across the country and occasionally overseas there is a lot of happening to happen. Greg has also had a career with the military and he brings some of that experience into this first entry at The Collective.

The term “those three little words” has the ability to strike at the heart and soul of anybody on the receiving end of them, but have you ever noticed how whilst the words can change, the outcome is invariably the same? Examples include:

If you are an emergency despatch operator the words could be: “He’s not breathing.”

For pilots and medical / nursing students they could be: “What’s that alarm?”

When holidaying on a cruise ship, how about: “We’re going down!”

If you’re a paratrooper they’d be “Green on, go” – which means some big guy with an even bigger boot is going to kick you off his dodgy Air Force aeroplane while it is still 300m above the ground.

If you work in the air and hate water it’s likely to be: “Time for HUET.”

But if you are a romantic or a fan of chick flics those three little words might be: “Oh, never mind” or variations of the same.

Note: Okay, the HUET one might just be me, but that’s a story for another time. As for the rest of the examples, if you hear those words you tend to spring into action.

But alas, this blog post is not about any of the above “three little words”. It’s about a topic that everyone has an opinion on, some have a degree of training in but most get confused about: Leadership, Management and Authority. If you were thinking something bizarre like “I love you” then you have sadly found the wrong blog site….unless you’re talking about helicopters, video laryngoscopes or the pre-hospital use of ketamine in which case uttering “I love you” might actually be appropriate.

A bit of personal background

For the first half of my working life I was a member the Australian Regular Army, starting out as a soldier and finishing up as an officer. Throughout that time I was exposed to some outstanding models of leadership, authority and management, some of which were during the most difficult of environments such as war zones and disaster areas. Then again, throughout that time I was also exposed to some of the worst examples of these three little words in action; experiences which, to this day, elicit a trembling response within me.

The net result of these experiences is that I believe that there is something to be gained out of every experience in life. Sometimes you will decide to model yourself on the behaviours you have seen enacted; other times you will decide to never, ever, EVER be like that person. Either way you are left better off; well, that’s in the world according to me.

Leadership

Now, the holders of MBA’s, MHA’s or other masters level qualifications specialising in “getting stuff done” will probably be expecting me to enter into a long diatribe of definitions, but still being a soldier at heart I like to keep things simple. To me, if I cannot recall and utilise a piece of information at 10am on a Tuesday at sea level then I am certainly not going to be able to apply it at 2am on a Sunday when at 20,000 feet with a crook patient. That’s why my preferred definition of leadership comes from a former soldier (okay, a General…and a pretty good one too) turn President of the United States of America, Dwight D. Eisenhower.

“Leadership is the art of getting someone else to do something you want done because he wants to do it.”

Seems simple enough, doesn’t it? As far as definitions of leadership go I reckon it covers the major points. Leadership is about influence, inspiration and motivation in order to achieve a specific outcome.

In case you had any doubts, just look at General Eisenhower leading from this jeep and tell me you wouldn’t do what he asked AND want to do it.

On one deployment with the Australian Army back in 2005 I had the privilege of meeting and talking with Colin Powell, another former US Army General turned Secretary of State. He remains, hands down, one of the most charismatic leaders I have ever met. He has a well published list of the 13 life rules for any future leader which can be found here (along with many other sites).

When you read them (and their descriptors) you will note that they strike at the heart of what it means to be a human being. Why? Good leaders need to be able to relate to people and people need to be able to relate to them; but great leaders are inspirational. It’s about influence, motivation and the ability to achieve an objective.

Management

One of my pet hates is the way the term “management” is thrown around. As clinicians we are required to “manage” a lot of things: manage the airway, manage the infusions, manage the waiting room in the local Emergency Department, manage the expectations of relatives, manage the deadly effects of “hypocaffeinaemia” amongst the team… But then there are department managers, nurse managers, operations managers too; in fact, at times I think that in life there are more “managers” than there are people or things to actually manage!

But what does it mean to actually “manage” something (or someone)?

Field Marshal Sir William Slim led the 14th British Army from 1943 to 1945 in the re-conquest of Burma from the Japanese – one of the most epic campaigns of WWII. He recognised the distinction between leaders and managers when he said:

“Managers are necessary; leaders are essential. Leadership is of the spirit, compounded by personality. Management is of the mind, more a matter of accurate calculation, statistics, methods, timetables and routine.

Management is about resources. Managers facilitate leaders; managers perform a series of acts which enable the doers to get on with the business of, well, doing stuff. Essentially, to “manage” means to ensure that the right “stuff” is in the right place at the right time – and if it’s not there, to get it there.

The third of those three little words is authority. In military speak it is more readily recognised as “Command”, and sometimes in combination such as “Command Authority”.

Now, for the purpose of this blog I am not talking about somebody who possesses an expert opinion (i.e. a guru who is considered an authority on a given topic). Rather I am referring to authority as being the authorised responsibility for the completion of a task.

Those who work in the aeromedical industry will be familiar with the phrase “Pilot In Command”. This phrase refers to the singular person who holds ultimate responsibility for the safety of the aircraft and its payload (passengers, crew and cargo). The key word here is responsibility. There exists a direct relationship between authority and responsibility – the person in the position of authority is the holder of top level responsibility which means that the buck stops with him or her. Decisions regarding the safe operation of the aircraft rest with him/her, but in conducting the flight the Pilot In Command remains open to the advice of the aircraft’s instruments, crew, ground staff etc. Authority is not the same as authoritarianism. The best commanders I have worked with engage the brains of those who surround them in an effort to make the best possible decisions.

Tying it altogether

But what does this mean to us as clinicians? Well, let’s use an everyday occurrence as an example: a stock standard cardiac arrest in the Emergency Department of the Royal [insert location here] Hospital….

Picture a team of dedicated and highly trained clinicians applying the evidence-based best practices that they have recently downloaded from their favourite FOAMed site and translated into policy speak for their local heath district. The team includes doctors, nurses, allied health professionals and clerical staff.

Standing at the head of the bed is a doctor / nurse combo charged with “managing” the airway. Whilst working as a team within the bigger team, the doctor is “leading” the procedure and the nurse is supporting. The doctor is holding responsibility for the airway but recognises that airway management is but one ingredient to achieving the best possible patient outcome. The airway doc feeds information to the leader of the entire resuscitation team in a closed loop manner and works within his/her scope but under the authority of the “Team Leader” who stands beyond arm’s reach of the patient.

Outside of the Resus Bay the rest of the Emergency Department continues to function albeit on reduced staffing. Leading the efforts out on the floor is a nurse (often referred to as a Nursing Unit Manager) who reallocates patient care tasks, adjusts meal break times, requests additional staff from the Hospital Administrators (and usually gets told that there are none available) and performs other important but behind the scenes tasks. Little wonder why this person is referred to as a “Manager”, hey?

Meanwhile, back in the Resus Bay (out of reach of the patient yet able to see and hear the conduct of the resuscitative efforts) stands another clinician. This person is observing the efforts of all other team members (airway team, circulation team, defib operator etc), guiding their actions, feeding information to the scribe and making informed decisions as to the resuscitation attempt. Hands in pockets (lest he/she feel the need to touch anything), eyes and ears wide open and brain well and truly engaged, this person is the “Team Leader” (really though this person should be called the Team Commander).

The authority the team leader wields is delegated to him/her by the health district’s administration (yep, those same people who won’t backfill the floor). Whilst each individual inside the Resus Bay is working within their own scope of practice, it is the “Team Leader” who holds responsibility for the patient. If need be the Team Leader can delegate his/her authority to another clinician for a set period (e.g. in order to undertake a specific procedure) but at some point the authority (and therefore responsibility) will be handed back.

Leadership, management and authority all play a role in our everyday lives as clinicians, be it inside a hospital, at the side of the road or at 20,000 feet. When it comes to the complexities of patient care leadership, management and authority exist in an intricate spider web of relationships that (hopefully) combine into a seamless hive of activity with a single focus – the patient.

Summary

Travelling waaaaay back in time to when I first received my commission as an officer in the Australian Army I was on leave at my parents’ house in Brisbane when the old school wall mounted telephone (you know, the one where you had to dial the number by actually turning the dial with your finger?) rang. It happened to be my “Head of Corps” (which is a very respectable position, especially when you are just a peon lieutenant like I was) looking for me.

On the eve of his retirement, the Colonel wanted to pass on some words of wisdom – words that he said had served him well throughout his illustrious career. He said,

“Never mess with your soldiers’ food or pay. If you feed them well, they will work hard with you, even if they don’t want to. If you pay them on time, their families can eat too which means that your soldiers won’t be distracted by life at home.”

I did not realise it at the time, but what he was giving me was a snapshot of what it meant to be an effective Army officer. Leadership is about inspiration and motivation. Management is about providing the right resources in the right place at the right time. Authority is about responsibility. One day I hope to be effective and efficient in the application of all three.